I presented this paper at Kolkata AICOG with data related to the IPV procedure ..it is now truly a disappearing art and postgraduates need dedicated teachers to develop the skills for proper selection and execution
"Internal podalic version- revival of a disappearing art"
INTERNAL PODALIC VERSION- Revival Of A Disappearing ArtDr Charu MittalMD, DNB, MICOG, MNAMSEx-Asst ProfessorMember FOGSI Quiz &Clinical Research CommitteesProf L.N ChauhanMD, DGOEx-Professor & HODMedical College, Baroda
INTRODUCTIONObstetric emergencies constitute a majorproblem in a tertiary care hospital, which isa referral centre for many nearby villages.Cases of advanced labour with transverse lieare a result of inadequate ANC & delayed access to health facilities.
• In cases where the fetus is dead in-utero, is pre-viable or has congenital anomalies not compatible with life, giving the mother a scar on her uterus with a dead baby predisposes her to more morbidity in this pregnancy & a high risk next pregnancy.• Performing Internal Podalic Version (IPV), a technique which requires expertise and art, will save a scar on the uterus, if performed in properly selected cases.
AIM AND OBJECTIVETo analyze the total number of cases oftransverse lie which reported at thelabor room of SSG Hospital, Baroda;which were managed by IPV, thusemphasizing its continuing importance in modern obstetrics.
MATERIALS AND METHODSRetrospective study involving labour room records ofall cases of transverse lie managed by IPV at labourroom of SSGH from January 1997 to December 2005.The total number of cases of IPV, socio-demographicfactors such as age, residential area, associatedobstetric complications, mode of presentation, parity,cervical dilatation at the time of IPV & complications ofIPV were studied and following observations weremade.
Table 2. SOCIO-DEMOGRAPHIC FACTORS Residence Number of cases % of cases Urban 05 9.3 % Semi-urban 04 7.4 % Rural 45 83.3 % Urban slum 00 00• None of them were booked cases.• 46% were emergency cases and 54% were referred.
Table 3. PARITY-WISE DISTRIBUTION OF CASES Parity No. of cases % of casesPrimigravida 05 9%2nd- 3rd gravida 40 74%4th- 5th gravida 08 15%> 5th gravida 01 2%Maximum number of cases of IPV were performed insecond and third gravida (74%).IPV done in patients who still want child-bearing cangive an advantage of preventing risk of a scar in afuture pregnancy.
Table 4. RELATION WITH WEEKS OF GESTATIONGEST.WEEKS NUMBER OF CASES % OF CASES26-28 wks 03 5%28-32wks 06 11%32-37wks 14 26%>37wks 31 58%Thus, utility of IPV need not be restricted topreterm fetuses alone.
5. ASSOCIATED OBSTETRIC CONDITIONMODE OF PRESENTATION NO. OF CASES % OF CASESShoulder presentation 12 22%Twins (2nd baby transverse) 02 4%Impacted shoulder 01 2%Hand prolapse 28 52%Cord prolapse 02 4%Cord with hand prolapse 04 7%Eclampsia 02 4%Placenta praevia 02 4%3rd degree cervical prolapse 01 2%
Maximum number of IPV were performed in c/ohand prolapse without impacted shoulder.IPV was done in 2 cases of eclampsia to acceleratethe delivery while preventing the morbidity &complications of LSCS in such cases.It was done successfully in 2 cases of placentaprevia type1 and 2A with a dead fetus & in one caseof impacted shoulder where there were no signs ofobstruction
Table 6. CERVICAL DILATATION AT THE TIME OF IPVDilatation of cervix No. of cases % of cases 3 / < 3 cm 01 2% 4 - 7 cm 10 18% > 7 cm 43 80%IPV can be easily and successfully attempted incases of dead baby in transverse lie at > 4 cmdilatation of the cervix.
Table 7. BIRTHWEIGHT Birth weight No. of cases % of cases < 1.5 KG 10 18.5% 1.5 – 2.0 KG 10 18.5% 2.0 – 3.0 KG 33 61.0% > 3.0 KG 01 2.0%In maximum number of cases the birth weight wasbetween 2 to 3 kgs suggesting that IPV can besuccessfully attempted at such birth weights.
Table 8. MORBIDITY PROFILEMorbidity No. of cases % of casesPerineal tear (1st degree) 01 7%Cervical tears 05 32%Vaginal tears 01 7%Para-labial tears 01 7%Para-urethral tears 06 40%Colporrhexis 01 7%Rupture uterus 00Obstetric shock 00Morbidity was present in 28% (15 / 54) of the cases ofIPV which was mainly due to cervical & para-urethraltears.
Table 9. SURGEON’S EXPERIENCEYears of experience No. of cases % of cases < 3 years 17 31% 3 - 5 years 10 19% > 5 years 27 50% The availability and presence of a senior surgeon with more experience increases the chances of success with attempted IPV.
FAILURE OF IPVFour such cases were reported. In three cases thereason was difficulty in reaching the foot by a lessexperienced operator (<3yrs). This was followed byLSCS.In fourth case the reason for failure was notmentioned. IPV was followed by evisceration andvaginal birth. MORTALITYThere was one maternal mortality which was notrelated to IPV or its complication but due to theassociated obstetric condition (eclampsia).
CONCLUSIONIPV was performed successfully in 15.7% cases oftransverse lie where fetus was either dead and / orpremature, cervix was sufficiently dilated and therewere no signs of obstruction.Timely referral services, early diagnosis & appropriateindication with management by an experienced personcan give good results in cases of transverse liemanaged by IPV.Such technical skill can be taught during residencytraining and maintained through use in clinical practice
This can prevent a scar on the uterus and morbiditydue to it in this pregnancy as well as in the nextpregnancy, as a mother with a dead baby with anLSCS done, is often a village woman who lives milesaway from the hospital and does not have facilities toattend the antenatal clinic regularly.While in certain cases of transverse lie where there is adanger of rupture uterus and complications fromintrauterine manipulations, it is better perform LSCS. Thus, management of all cases of Transverse Lie should be tailored accordingly.